Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study

BACKGROUND Fecal incontinence(FI)is an involuntary passage of fecal matter which can have a significant impact on a patient’s quality of life.Many modalities of treatment exist for FI.Sacral nerve stimulation is a well-established treatment for FI.Given the increased need of magnetic resonance imaging(MRI)for diagnostics,the In-terStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility.Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used.AIM To evaluate the efficacy,outcomes and complications of the MRI-compatible InterStim.METHODS Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport,University of Minnesota,Advocate Lutheran General Hospital,and University of Wisconsin-Madison was pooled and analyzed.Patient demographics,clinical features,surgical techniques,complications,and outcomes were analyzed.Strengthening the Reporting of Observational studies in Epidemiology(STROBE)cross-sectional reporting guidelines were used.RESULTS Seventy-three patients had the InterStim implanted.The mean age was 63.29±12.2 years.Fifty-seven(78.1%)patients were females and forty-two(57.5%)patients had diabetes.In addition to incontinence,overlapping symptoms included diarrhea(23.3%),fecal urgency(58.9%),and urinary incontinence(28.8%).Fifteen(20.5%)patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement.Thirty-two(43.8%)patients underwent rechargeable InterStim placement.Three(4.1%)patients needed removal of the implant.Migration of the external lead connection was observed in 7(9.6%)patients after the stage I procedure.The explanation for one patient was due to infection.Seven(9.6%)patients had other complications like nerve pain,hematoma,infection,lead fracture,and bleeding.The mean follow-up was 6.62±3.5 mo.Sixty-eight(93.2%)patients reported significant improvement of symptoms on follow-up evaluation.CONCLUSION This study shows promising results with significant symptom improvement,good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI.Further long-term follow-up and future studies with a larger patient population is recommended.

Medium-term surgical outcomes and health-related quality of life after laparoscopic vs open colorectal cancer resection: SF-36 health survey questionnaire

BACKGROUND Previous studies that compared the postoperative health-related quality of life(HRQoL)outcomes after receiving laparoscopic resection(LR)or open resection(OR)in patients with colorectal cancer(CRC)have different conclusions.AIM To explore the medium-term effect of postoperative HRQoL in such patients.METHODS This study randomized 567 patients undergoing non-metastatic CRC surgery managed by one surgeon to the LR or OR groups.HRQoL was assessed during the preoperative period and 3,6,and 12 mo postoperative using a modified version of the 36-Item Short Form(SF-36)Health Survey questionnaire,emphasizing eight specific items.RESULTS This cohort randomly assigned 541 patients to receive LR(n=296)or OR(n=245)surgical procedures.More episodes of postoperative urinary tract infection(P<0.001),wound infection(P<0.001),and pneumonia(P=0.048)were encountered in the OR group.The results demonstrated that the LR group subjectively gained mildly better general health(P=0.045),moderately better physical activity(P=0.006),and significantly better social function recovery(P=0.0001)3 mo postoperatively.Only the aspect of social function recovery was claimed at 6 mo,with a significant advantage in the LR group(P=0.001).No clinical difference was found in HRQoL during the 12 mo.CONCLUSION Our results demonstrated that LR resulted in better outcomes,including intra-operative blood loss,surgery-related complications,course of recovery,and especially some health domains of HRQoL at least within 6 mo postoperatively.Patients should undergo LR if there is no contraindication.

A prospective randomized trial of transnasal ileus tube vs nasogastric tube for adhesive small bowel obstruction

AIM:To study the therapeutic efficacy of a new transnasal ileus tube advanced endoscopically for adhesive small bowel obstruction.METHODS:A total of 186 patients with adhesive small bowel obstruction treated from September 2007 to February 2011 were enrolled into this prospective randomized controlled study.The endoscopically advanced new ileus tube was used for gastrointestinal decompression in 96 patients and ordinary nasogastric tube(NGT) was used in 90 patients.The therapeutic efficacy was compared between the two groups.RESULTS:Compared with the NGT group,the ileus tube group experienced significantly shorter time for relief of clinical symptoms and improvement in the findings of abdominal radiograph(4.1 ± 2.3 d vs 8.5 ± 5.0 d) and laboratory tests(P < 0.01).The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group(P < 0.01).And 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery.For recurrent adhesive bowel obstruction,ileus tube was also significantly more effective than NGT(95.8% vs 31.6%).In the ileus tube group,the drainage output on the first day and the length of hospital stay were significantly different depending on the treatment success or failure(P < 0.05).The abdominal radiographic improvement was correlated with whether or not the patient underwent surgery.CONCLUSION:Ileus tube can be used for adhesive small bowel obstruction.Endoscopic placement of the ileus tube is convenient and worthy to be promoted despite the potential risks.

Colorectal cancer in patients under 50 years of age:A retrospective analysis of two institutions' experience

AIM:To investigate the epidemiological characteristics of colorectal cancer(CRC)in patients under 50 years of age across two institutions.METHODS:Records of patients under age 50 years of age who had CRC surgery over a 16 year period were assessed at two institutions.The following documents where reviewed:admission notes,operative notes,and discharge summaries.The main study variables included:age,presenting symptoms,family history,tumor location,operation,stage/differentiation of disease,and post operative complications.Stage of disease was classified according to the American Joint Committee on Cancer TNM staging system:tumor depth;node status;and metastases.RESULTS:CRC was found in 180 patients under age50 years(87 females,93 males;mean age 41.4±6.2years).Young patients accounted for 11.2%of cases during a 6 year period for which the full data set wasavailable.Eight percent had a 1stdegree and 12%a 2nd degree family CRC history.Almost all patients(94%)were symptomatic at diagnosis;common symptoms included:bleeding(59%),obstruction(9%),and abdominal/rectal pain(35%).Evaluation was often delayed and bleeding frequently attributed to hemorrhoids.Advanced stage CRC(Stage 3 or 4)was noted in 53%of patients.Most tumors were distal to the splenic flexure(77%)and 39%involved the rectum.Most patients(95%)had segmental resections;6 patients had subtotal/total colectomy.Poorly differentiated tumors were noted in 12%and mucinous lesions in 19%of patients of which most had Stage 3 or 4 disease.Twenty-two patients(13%)developed recurrence and/or progression of disease to date.Three patients(ages 42,42and 49 years)went on to develop metachronous primary colon cancers within 3 to 4 years of their initial resection.CONCLUSION:CRC was common in young patients with no family history.Young patients with symptoms merit a timely evaluation to avoid presentation with late stage CRC.

Ratio of metastatic lymph nodes is more important for rectal cancer patients treated with preoperative chemoradiotherapy

AIM:To evaluate the predictive value of the lymph node(LN) ratio(LNR,number of metastatic LNs/ examined LNs) for recurrence in patients with rectal cancer and to compare its applicability according to preoperative chemoradiotherapy(PCRT).METHODS:From 2000 to 2009,967 patients with metastatic LNs after curative resection for locally advanced rectal cancer were identified.Patients were categorized according to PCRT(PCRT vs No PCRT).The cut-off LNR was determined based on the p N1 vs p N2 when the recommended number of LNs was harvested.The 5-year recurrence-free survival(RFS) rates using the Kaplan-Meier method were compared according to p/yp N stage and the LNR in each group.RESULTS:Among patients with the same p/yp N stage,the 5-year RFS rate differed according to the LNR.In addition,the 5-year RFS rate was significantly different between p N and LNR groups in patients with No PCRT.In PCRT group,however,only LNR was associated with prognosis.On multivariate analysis,both p N and LNR were significant independent prognostic factors for 5-year RFS in the No PCRT group.In the PCRT group,only LNR category was found to be associated with RFS(HR = 2.36,95%CI:1.31-3.84,and P = 0.001).CONCLUSION:The LNR is an important prognostic predictor of RFS in rectal cancer patients especially treated with PCRT.Current p N categories could not discriminate between prognostic groups of RFS after PCRT.

Impression of prognosis regarding pathologic stage after preoperative chemoradiotherapy in rectal cancer

AIM: To ascertain pathologic stage as a prognostic indicator for rectal cancer patients receiving preoperative chemoradiotherapy(PCRT).METHODS: Patients with mid- and low rectal carcinoma(magnetic resonance imaging- based clinical stage Ⅱ or Ⅲ) between 2000 and 2009 and treated with curative radical resection were identified. Patients were divided into two groups: PCRT and No-PCRT. Recurrence-free survival(RFS) was examined according to pathologic stage and addition of adjuvant treatment.RESULTS: Overall, 894 patients were identified. Of these, 500 patients received PCRT. Adjuvant chemotherapy was delivered to 81.5% of the No-PCRT and 94.8% of the PCRT patients. Adjuvant radiotherapy was given to 29.4% of the patients in the No PCRT group. The 5-year RFS for the No-PCRT group was 92.6% for StageⅠ, 83.3% for Stage Ⅱ, and 72.9% for Stage Ⅲ. The 5-year RFS for the PCRT group was 95.2% for yp Stage 0, 91.7% for yp StageⅠ, 73.9% for yp Stage Ⅱ, and 50.7% for yp Stage Ⅲ.CONCLUSION: Pathologic stage can predict prognosis in PCRT patients. Five-year RFS is significantly lower among PCRT patients than No-PCRT patients in pathologic stage Ⅱ and Ⅲ. These results should be taken into account when considering adjuvant treatment for patients treated with PCRT.

Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn's disease: Propensityscore matching analysis

BACKGROUND Laparoscopic ileocolic resection(LICR)is the preferred surgical approach for primary ileocolic Crohn’s disease(CD)because it has greater recovery benefits than open ICR(OICR).AIM To compare short-and long-term outcomes in patients who underwent LICR and OICR.METHODS Patients who underwent ICR for primary CD from 2006 to 2017 at a single tertiary center specializing in CD were included.Patients who underwent LICR and OICR were subjected to propensity-score matching analysis.Patients were propensityscore matched 1:1 by factors potentially associated with 30-d perioperative morbidity.These included demographic characteristics and disease-and treatment-related variables.Factors were compared using univariate and multivariate analyses.Long-term surgical recurrence-free survival(SRFS)in the two groups was determined by the Kaplan-Meier method and compared by the log-rank test.RESULTS During the study period,348 patients underwent ICR,211 by the open approach and 137 laparoscopically.Propensity-score matching yielded 102 pairs of patients.The rate of postoperative complication was significantly lower(14%versus 32%,P=0.003),postoperative hospital stay significantly shorter(8 d versus 13 d,P=0.003),and postoperative pain on day 7 significantly lower(1.4 versus 2.3,P<0.001)in propensity-score matched patients who underwent LICR than in those who underwent OICR.Multivariate analysis showed that postoperative complications were significantly associated with preoperative treatment with biologics[odds ratio(OR):3.14,P=0.01]and an open approach to surgery(OR:2.86,P=0.005).The 5-and 10-year SRFS rates in the matched pairs were 92.9%and 83.3%,respectively,with SRFS rates not differing significantly between the OICR and LICR groups.The performance of additional procedures was an independent risk factor for surgical recurrence[hazard ratio(HR):3.28,P=0.02].CONCLUSION LICR yielded better short-term outcomes and postoperative recovery than OICR,with no differences in long-term outcomes.LICR may provide greater benefits in selected patients with primary CD.

Vedolizumab in Crohn’s disease with rectal fistulas and presacral abscess:A case report

BACKGROUND Fistula and intraabdominal abscess are common complications of Crohn’s disease(CD),but complex rectal fistula with abscess formation is rare.Tumor necrosis factor antagonists combined with percutaneous drainage or surgical intervention is optimal treatment for fistulizing CD with intraabdominal abscess.There is no study showing the efficacy of vedolizumab in such complicated condition.CASE SUMMARY A 47-year-old man has decompensated liver cirrhosis,Child B.He suffered from abdominal pain,bloody diarrhea,fever,and body weight loss.CD with rectoprostatic fistula,rectopresacral fistula,presacral abscess and cytomegalovirus(CMV)infection were noted.He received antibiotics,anti-viral therapy,transverse colostomy and vedolizumab treatment.Six months later,he had deep remission and complete fistula tracts closure.CONCLUSION Early vedolizumab and stool diversion are effective and safe in treating CD with complex rectal fistula with abscess formation.

Surgical outcomes of Korean ulcerative colitis patients with and without colitis-associated cancer

AIM: To determine the clinicopathologic characteristics of surgically treated ulcerative colitis(UC) patients, and to compare the characteristics of UC patients with colitis-associated cancer(CAC) to those without CAC. METHODS: Clinical data on UC patients who underwent abdominal surgery from 1980 to 2013 were collected from 11 medical institutions. Data were analyzed to compare the clinical features of patients with CAC and those of patients without CAC.RESULTS: Among 415 UC patients, 383(92.2%) underwent total proctocolectomy, and of these, 342(89%) were subjected to ileal pouch-anal anastomosis. CAC was found in 47 patients(11.3%). Adenocarcinoma was found in 45 patients, and the others had either neuroendocrine carcinoma or lymphoma. Comparing the UC patients with and without CAC, the UC patients with CAC were characteristically older at the time of diagnosis, had longer disease duration, underwent frequent laparoscopic surgery, and were infrequently given preoperative steroid therapy(P < 0.001-0.035). During the 37 mo mean follow-up period, the 3-yearoverall survival rate was 82.2%.CONCLUSION: Most Korean UC patients experience early disease exacerbation or complications. Approximately 10% of UC patients had CAC, and UC patients with CAC had a later diagnosis, a longer disease duration, and less steroid treatment than UC patients without CAC.

Evaluating the benefit of adjuvant chemotherapy in patients with ypT0-1 rectal cancer treated with preoperative chemoradiotherapy

BACKGROUND Adjuvant chemotherapy(ACTx)is recommended in rectal cancer patients after preoperative chemoradiotherapy(PCRT),but its efficacy in patients in the early post-surgical stage who have a favorable prognosis is controversial.AIM To evaluate the long-term survival benefit of ACTx in patients with ypT0–1 rectal cancer after PCRT and surgical resection.METHODS We identified rectal cancer patients who underwent PCRT followed by surgical resection at the Asan Medical Center from 2005 to 2014.Patients with ypT0–1 disease and those who received ACTx were included.The 5-year overall survival(OS)and 5-year recurrence-free survival(RFS)were analyzed according to the status of the ACTx.RESULTS Of 520 included patients,413 received ACTx(ACTx group)and 107 did not(no ACTx group).No significant difference was observed in 5-year RFS(ACTx group,87.9%vs no ACTx group,91.4%,P=0.457)and 5-year OS(ACTx group,90.5%vs no ACTx group,86.2%,P=0.304)between the groups.cT stage was associated with RFS and OS in multivariate analysis[hazard ratio(HR):2.57,95%confidence interval(CI):1.07–6.16,P=0.04 and HR:2.27,95%CI:1.09–4.74,P=0.03,respectively].Furthermore,ypN stage was associated with RFS and OS(HR:4.74,95%CI:2.39–9.42,P<0.00 and HR:4.33,95%CI:2.20–8.53,P<0.00,respectively),but only in the radical resection group.CONCLUSION Oncological outcomes of patients with ypT0–1 rectal cancer who received ACTx after PCRT showed no improvement,regardless of the radicality of resection.Further trials are needed to evaluate the efficacy of ACTx in these group of patients.

Current issues in locally advanced colorectal cancer treated by preoperative chemoradiotherapy

In patients with locally advanced rectal cancer, preoperative chemoradiotherapy has proven to significantly improve local control and cause lower treatment-related toxicity compared with postoperative adjuvant treatment. Preoperative chemoradiotherapy followed by total mesorectal excision or tumor specific mesorectal excision has evolved as the standard treatment for locally advanced rectal cancer. The paradigm shift from postoperative to preoperative therapy has raised a series of concerns however that have practical clinical implications. These include the method used to predict patients who will show good response, sphincter preservation, the application of conservative management such as local excision or &#x0201c;wait-and-watch&#x0201d; in patients obtaining a good response following preoperative chemoradiotherapy, and the role of adjuvant chemotherapy. This review addresses these current issues in patients with locally advanced rectal cancer treated by preoperative chemoradiotherapy.

Could tumor characteristics identified by colonoscopy predict the locally advanced rectal carcinoma？

Background Neoadjuvant chemoradiation is now considered the standard care for locally advanced rectal carcinoma （T3-4 or/and N1-2 lesions）, but the accuracy of staging examinations including endorectal ultrasonography （ERUS） and MRI is far from excellent. In addition, the above staging equipment or professionals who perform the examinations may not be available in some hospitals, while preoperative colonoscopy and biopsy are usually obtainable in most hospitals.The objective of the present study was to investigate the clinical and pathological characteristics of locally advanced rectal carcinoma and identify candidates for neoadjuvant chemoradiation.Methods This was a retrospective study. Patients who were treated for rectal cancer at Changhai Hospital from January 1999 to July 2008 were identified from our prospectively collected database. Statistical analysis was performed using SPSS Software System （version 15.0）. The Mann-Whitney test, chi-square test and multivariate Logistic regression analysis were performed,Results A total of 1005 cases were included in this research, of which 761 cases were identified as locally advanced rectal carcinoma depending on postoperative TNM staging. The results of multivariate Logistic regression analysis indicated seven independent risk factors that could be used to predict a locally advanced rectal carcinoma independently： a high grade （including poor differentiation and undifferentiation） （OR： 3.856; 95% CI： 2.064 to 7.204;P=0.000）; large tumor size （OR： 2.455; 95% CI： 1.755 to 3.436; P=0.000）; elevated preoperative serum CEA level （OR：1.823; 95% CI： 1.309 to 2.537; P=0.000）; non-polypoid tumor type （OR： 1.758; 95% CI： 1.273 to 2.427; P=0.001）; the absence of synchronous polyps （OR： 1.602; 95% CI： 1.103 to 2.327; P=0.013）; the absence of blood in stool （OR： 1.659;95% CI： 1.049 to 2.624; P=0.030）; and a greater circumferential tumor extent （OR： 1.813; 95% CI： 1.055 to 3,113;P=0.031）. Based on these findings, a Logistic equation was established, the accuracy of which was 64% according to the information of the additional 50 cases.Conclusions Some independent risk factors related with locally advanced rectal carcinoma were identified, based on which it is possible to establish a Logistic equation as a tool to predict candidates of neoadjuvant chemoradiation.Further research about optimization of the equation is warranted.

Non-physician endoscopists: A systematic review

AIM:To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal(GI) endoscopy services.METHODS:The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms.Studies were screened against eligibility criteria and for relevance.Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of nonphysician endoscopists.These publications included a total of 28883 procedures performed by non-physician endoscopists.RESULTS:The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter.17/26 studies related to flexible sigmoidoscopies,5 to upper GI endoscopy and 6 to colonoscopy.All studies were from metropolitan centres with nurses working under strict supervision and guidance by specialist gastroenterologists.Geographic distribution of publications showed the majority of research was conducted in the United States(43%),the United Kingdom(39%)and the Netherlands(7%).Most studies conclude that after appropriate training nurseendoscopists safely perform procedures.However,in relation to endoscopic competency,safety or patient satisfaction,all studies had major methodological limitations.Patients were often not randomized(21/26studies)and not appropriately controlled.In relation to cost-efficiency,nurse endoscopists were less costeffective per procedure at year 1 when compared to services provided by physicians,due largely to the increased need for subsequent endoscopies,specialist follow-up and primary care consultations.CONCLUSION:Contrary to general beliefs,endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite.Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.

The“terminal line”:a novel sign for the identification of distal mesorectum end during TME for rectal cancer

Background:Although the clinical importance of complete,intact total mesorectal excision(TME)is the widely accepted standard for decreasing local recurrence of rectal cancer,the residual mesorectum still represents a significant component of resection margin involvement.This study aimed to use a visible intraoperative sign to detect the distal mesorectal end to ensure complete inclusion of the mesorectum and avoid unnecessary over-dissection.Methods:The distal mesorectum end was investigated retrospectively through a review of 124 operative videos at the Union Hospital of Fujian Medical University(Fujian,China)and Cleveland Clinic(Ohio,USA)by two independent surgeons who were blinded to each other.Furthermore,28 cadavers and 44 post-operative specimens were prospectively examined by hematoxylin and eosin(H&E)staining and Masson’s staining to validate and confirm the findings of the retrospective part.Univariate and multivariate analyses were carried out to detect the independent factors that can affect the visualization of the distal mesorectal end.Results:The terminal line(TL)is the distal mesorectal end of the transabdominal and transanal TME(taTME)and appears as a remarkable pearly white fascial structure extending posteriorly from 2 to 10 o’clock.Histopathological examination revealed that the fascia propria of the rectum merges with the presacral fascia at the TL,beyond which the mesorectum ends,with no further downward extension.In the retrospective observation,the TL was seen in 56.6%of transabdominal TME and 56.0%of taTME operations.Surgical approach and tumor distance from the anal verge were the independent variables that directly influenced the detection of the TL(P=0.03 and P=0.01).Conclusion: The TL is a visible sign where the transabdominal TME should end and the taTME should begin. Recognitionof the mesorectal end may impact the certainty of complete mesorectum inclusion. Further clinical trials are needed toconfirm the preliminary findings.

通过一种新型甘油透明质酸钠/羧甲纤维素生物可吸收生物膜预防术后腹腔粘连:一项前瞻性、随机、盲法评估的多中心研究

INTRODUCTION: Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/ carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients. METHODS: Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no antiadhesion treatment (control) or treat-ment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision. RESULTS: Data were analyzed using the intent-to-treat population. Treatment with glycerol hyalurona-te/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative ad-hesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose. CONCLUSIONS: Glycerol hyalurona-te/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications.

控制式回肠造口术:目前经验

PURPOSE: This study was designed to review our recent experience with continent ileostomies and evaluate patient outcomes. METHODS: Retrospective chart reviews and phone interviews of patients who underwent a continent ileostomy operation from 1993 to 2003 at the Ochsner Clinic Foundation were performed. RESULTS: Twenty-four patients (19 females; age range, 22- 73 years) had construction of continent ileostomies (modified Kock pouch). There were no intraoperative mortalities or stoma-related deaths. The mean operating room time for primary constructionwas 3.9 ± 0.57 hours with a mean length of stay of 7 ± 2 days. The average follow-up period was 66 (range, 6- 134) months. The most common underlying indication for the construction of a continent ileostomy was ulcerative colitis (71 percent). Thirteen patients had a co-ntinent ileostomy created for conversion of a Brooke ileostomy and seven for a failed ileoanal pouch. Other indications included colonic inertia and incontinence in three patients and one patient who had failed multiple operations for Hirschsprung’s disease. A total of 28 revisions were performed in 14 patients (58 percent). Six patients requir-ed multiple procedures. Operative revisions included 12 skin level revision for stenosis, 11 operations for valve repairs, and 1 each for peristomal hernia repair, stomal relocation, and pouch repair for fistulas. Two patients had their pouches removed (Crohn’s disease and inability to manage pouch). The need for revision by 12 months was 29 percent, and the average time period before the first revision was 24 months (range, 4 days to 109 months). The overall failure rate (converted to conventional ileostomy)was only 8.3 percent. Ninety percent of the patients have continent pouches and are satisfied with their pouch function. CONCLUSIONS: Continent ileostomies continue to have a high rate of reoperations, reasonable functional results, and are a viable option for failed ileal pouch anal pouch patients. Surgeons electing to perform continent ileostomies must carefully select their patients and advise them of the high potential for reoperations. Despite a high reoperation rate, patients are pleased with their continent ileostomies.

Epidermolytic acanthoma:A case report

BACKGROUND Epidermolytic acanthoma(EA)is a rare benign skin lesion,usually found in the genital area of men and women,with epidermolytic hyperkeratosis as its distinguishing histologic characteristic.It is commonly misdiagnosed as condyloma accuminatum,verruca,and seborrheic keratosis.Since this lesion is benign,treatment is not necessary.However,it is often misdiagnosed,and patients are likely to undergo incorrect counseling and unnecessary treatment,causing undue burden to the patient.This study seeks to increase awareness of this rare condition to prevent future misdiagnoses.CASE SUMMARY A 55-year-old man living with human immunodeficiency virus presented for anal cancer screening.His physical examination revealed a flesh colored papule at the anal margin.The initial differential diagnosis included molluscum contagiosum,anal condyloma,and basal cell carcinoma.The lesion was excised to obtain a definitive diagnosis and was discovered to be EA.CONCLUSION EA is often misdiagnosed due to its similarity to other dermatologic conditions.Careful examination and pathologic evaluation should be obtained to ensure proper diagnosis.

可控性回肠造口术的远期预后与生活质量

INTRODUCTION:This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy,identify factors associated with adverse outcomes,and compare changes in quality of life after removal of the reservoir.METHODS:The records of all patients(n = 330)undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed.Patient-related,intraoperative,and postoperative factors were evaluated as predictor variables of long-term pouch survival.Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale(n = 216).These were compared between patients with continent ileostomy(n = 181)and patients who underwent removal of the continent ileostomy and conversion to an end stoma(n = 35).RESULTS:The median patient follow-up was 11(range,1-27)years.The median revision-free pouch interval was 14(95 percent confidence interval,11-17)months.The 10-year and 20-year pouch survival was 87 and 77 percent,respectively.Patients had an average of 3.7(range,1-28)complications and 2.9(range,1-27)pouch revisions during follow-up.On multivariate analysis,Crohn’s disease(hazard ratio = 4.5),female gender(hazard ratio = 2.4),fistula development(hazard ratio = 3),and body mass index(hazard ratio = 2.4 per 5 unit increase)were independent predictors of pouch failure.Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy.CONCLUSIONS:Despite the associated morbidity with continent ileostomy surgery,long-term results and quality of life were encouraging.Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy.

美国结直肠外科医师协会2019版藏毛窦诊治临床实践指南

美国结直肠外科医师协会(The American Society of Colon and Rectal Surgeons,ASCRS)于2019年2月公布了最新的藏毛窦诊治临床实践指南。指南是由国际知名结直肠外科专家组成的临床实践指南委员会修订,对藏毛窦的一些争议进行了汇总和分析。